Family Services of Southeast Texas strengthens families through accessible, affordable counseling services and education for issues affecting family life, mental health and employment. We also provide comprehensive domestic violence shelter and support services. read more >>

Family Services of the North Shore is about to enter our third accreditation cycle with COA. Accreditation has provided us with a framework that enables us to demonstrate accountability to our clients, our funders and our donors. There is no question that the accreditation process and COA have benefited our agency. read more>>

FOC

RPM 8: Access to Case Records

Related

Interpretation:Organizations are expected to have policies and procedures that address access to case records by service recipients.

Interpretation:For networks, RPM 8 applies to case records and case information that is maintained by the network management entity, as well as records maintained by members of organizations or subcontracted providers.

Note:See DV 17 for further guidance about the information to be included in case records for Domestic Violence Services (DV).

Note:If the organization operates a program that qualifies for an NA but also provides other types of services, the standards should be implemented in all programs aside from those that qualify for the NA.

Related

Interpretation:Case records should not be left in public areas such as on carts in hallways, on desks, or in non-secured areas. When not being used by authorized staff, files should be returned to a secure area.

Rating Indicators

1

The organization's practices reflect full implementation of the standard.

2

Practices are basically sound but there is room for improvement; e.g.,

Record access policy or procedure needs strengthening.

3

Practice requires significant improvement; e.g.,

Record access policy or procedure needs significant strengthening; or

In a few instances the organization does not comply with the standard.

4

Implementation of the standard is minimal or there is no evidence of implementation at all.

RPM8.02

Reviews of case records by service recipients are:

conducted in the presence of professional personnel on the organization’s premises; and

carried out in a manner that protects the confidentiality of family members and others whose information may be contained in the record.

Related

Interpretation: For organizations using electronic record systems, allowing the service recipient to directly access the case record through a staff account represents a security risk. Access for service recipients may be provided, for example, through a separate user portal or by printing the case record.

Rating Indicators

1

The organization's practices reflect full implementation of the standard.

2

Practices are basically sound but there is room for improvement; e.g.,

Record access policy or procedure needs strengthening.

3

Practice requires significant improvement; e.g.,

Record access policy or procedure needs significant strengthening; or

In a few instances the organization does not comply with the standard.

4

Implementation of the standard is minimal or there is no evidence of implementation at all.

FP

RPM8.03

If the organization determines that it would be harmful for a service recipient to review his/her case record, and applicable law provides no guidance on case record access, then:

senior management reviews, approves in writing, and enters into the case record the reasons for refusal; and

procedures permit a qualified professional to review records on behalf of service recipients, provided the professional signs a statement that information determined to be harmful will be withheld.

Interpretation:An individual’s right to review his or her care or treatment may be denied, or otherwise limited, only in the most extreme circumstances where serious harm is likely to ensue. In such cases, objective criteria must guide decisions to deny access. In all cases, the organization must operate in accord with applicable law.

Rating Indicators

1

The organization's practices reflect full implementation of the standard.

2

Practices are basically sound but there is room for improvement; e.g.,

Record access policy or procedure needs strengthening.

3

Practice requires significant improvement; e.g.,

Record access policy or procedure needs significant strengthening; or

In a few instances the organization does not comply with the standard.

4

Implementation of the standard is minimal or there is no evidence of implementation at all.

RPM8.04

Contracts with subcontracted provider organizations and independent practitioners ensure that the network management entity has access to the case records of persons and families receiving network services.